HealthyAdvantage Primary Plan (HMO)
(H4454-028)

by HealthSpring - Mcminn County, TN

The plan offers national in-network prescription coverage. This means that you will pay the same amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).

Contact Information

Healthspring Of Tennessee Inc.
530 Great Circle Road
Nashville, TN 37228

Phone: 1-800-668-3813
Toll free: 1-800-668-3813

Website
http://www.healthspring.com

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Compare Plan Plan details

Plan Rating	3.5 out of 5 stars
Premium and Other Important Information	$27.1 monthly plan premium in addition to your monthly Medicare Part B premium.
	Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
	$3 400 out-of-pocket limit for Medicare-covered services.

Doctor and Hospital Choice	You must go to network doctors specialists and hospitals.
	Referral required for network hospitals and specialists (for certain benefits).

Inpatient Hospital Care	Plan covers 90 days each benefit period.
	$500 copay for each Medicare-covered hospital stay
	Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.
	Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.

Inpatient Mental Health Care	You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.
	For Medicare-covered hospital stays:
	Days 1 - 7: $200 copay per day
	Days 8 - 90: $0 copay per day
	Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.

Skilled Nursing Facility (SNF)	Authorization rules may apply.
	Plan covers up to 100 days each benefit period
	No prior hospital stay is required.
	$0 copay for SNF services

Home Health Care	Authorization rules may apply.
	$0 copay for Medicare-covered home health visits

Hospice	You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice.

Doctor Office Visits	Authorization rules may apply.
	$0 copay for each primary care doctor visit for Medicare-covered benefits.
	$0 copay for the cost of each in-area network urgent care Medicare-covered visit.
	$0 copay for each specialist doctor visit for Medicare-covered benefits.

Chiropractic Services	Authorization rules may apply.
	$0 copay for Medicare-covered chiropractic visits
	Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

Podiatry Services	Authorization rules may apply.
	$0 copay for Medicare-covered podiatry benefits.
	Medicare-covered podiatry benefits are for medically-necessary foot care.

Outpatient Mental Health Care	Authorization rules may apply.
	$0 copay for Medicare-covered Mental Health visits
	10% of the cost for Medicare-covered partial hospitalization program services

Outpatient Substance Abuse Care	Authorization rules may apply.
	10% of the cost for Medicare-covered individual visits
	10% of the cost for Medicare-covered group visits

Outpatient Services/Surgery	Authorization rules may apply.
	$0 copay for each Medicare-covered ambulatory surgical center visit
	0% to 10% of the cost for each Medicare-covered outpatient hospital facility visit

Ambulance Services	Authorization rules may apply.
	10% of the cost for Medicare-covered ambulance benefits.

Emergency Care	$65 copay for Medicare-covered emergency room visits
	$50 000 plan coverage limit for emergency services outside the U.S. every year.
	If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit.

Urgently Needed Care	$0 copay for Medicare-covered urgently-needed-care visits

Outpatient Rehabilitation Services	Authorization rules may apply.
	$0 copay for Medicare-covered Occupational Therapy visits
	$0 copay for Medicare-covered Physical and/or Speech and Language Therapy visits

Durable Medical Equipment	Authorization rules may apply.
	20% of the cost for Medicare-covered items

Prosthetic Devices	Authorization rules may apply.
	20% of the cost for Medicare-covered items

Diabetes Programs and Supplies	Authorization rules may apply.
	$0 copay for Diabetes self-management training
	0% to 20% of the cost for Diabetes monitoring supplies
	20% of the cost for Therapeutic shoes or inserts

Diagnostic Tests X-Rays Lab Services and Radiology Services	Authorization rules may apply.
	0% of the cost for Medicare-covered lab services
	0% to 10% of the cost for Medicare-covered diagnostic procedures and tests
	0% of the cost for Medicare-covered X-rays
	0% to 10% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)
	10% of the cost for Medicare-covered therapeutic radiology services

Cardiac and Pulmonary Rehabilitation Services	Authorization rules may apply.
	$0 copay for:
	Medicare-covered Cardiac Rehabilitation Services
	Medicare-covered Intensive Cardiac Rehabilitation Services
	Medicare-covered Pulmonary Rehabilitation Services

Preventive Services and Wellness/Education Programs	$0 copay for all preventive services covered under Original Medicare at zero cost sharing: Abdominal Aortic Aneurysm screening Bone Mass Measurement Cardiovascular Screening Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam) Colorectal Cancer Screening Diabetes Screening Influenza Vaccine Hepatitis B Vaccine HIV Screening Breast Cancer Screening (Mammogram) Medical Nutrition Therapy Services Personalized Prevention Plan Services (Annual Wellness Visits) Pneumococcal Vaccine Prostate Cancer Screening (Prostate Specific Antigen (PSA) test only) Smoking Cessation (Counseling to stop smoking) Welcome to Medicare Physical Exam (Initial Preventive Physical Exam)
	HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Please contact plan for details.
	This plan does not cover supplemental education/wellness programs.

Kidney Disease and Conditions	Authorization rules may apply.
	10% of the cost for renal dialysis
	$0 copay for kidney disease education services

Outpatient Prescription Drugs	20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.
	This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.healthspring.com on the web.
	Different out-of-pocket costs may apply for people who have limited incomes live in long term care facilities or have access to Indian/Tribal/Urban (Indian Health Service) providers.
	The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).
	Total yearly drug costs are the total drug costs paid by both you and a Part D plan.
	The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.
	Some drugs have quantity limits.
	Your provider must get prior authorization from HealthyAdvantage Primary Plan (HMO) for certain drugs.
	You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.
	If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount.
	$320 annual deductible.
	After you pay your yearly deductible you pay 25% until total yearly drug costs reach $2 930.
	You can get drugs the following way(s):
	one-month (30-day) supply
	three-month (90-day) supply
	Not all drugs are available at this extended day supply. Please contact the plan for more information.
	You can get drugs the following way(s):
	one-month (31-day) supply
	You can get drugs the following way(s):
	three-month (90-day) supply
	Not all drugs are available at this extended day supply. Please contact the plan for more information.
	After your total yearly drug costs reach $2 930 you receive a discount on brand name drugs and pay 86% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 700.
	After your yearly out-of-pocket drug costs reach $4 700 you pay the greater of: 5% coinsurance or $2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs.
	Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from HealthyAdvantage Primary Plan (HMO).
	You can get drugs the following way:
	one-month (30-day) supply
	After you pay your yearly deductible you will be reimbursed up to 75% of the actual cost for drugs purchased out-of-network until your total yearly drug costs reach $2 930.
	You will be reimbursed up to 14% of the plan allowable cost for generic drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 700. You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 700.
	After your yearly out-of-pocket drug costs reach $4 700 you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share which is the greater of: 5% coinsurance or $2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs.

Dental Services	Authorization rules may apply.
	$0 copay for Medicare-covered dental benefits
	$0 copay for the following preventive dental benefits:
	up to 1 oral exam(s) every six months
	up to 1 cleaning(s) every six months
	up to 1 dental x-ray(s) every year
	$1 000 plan coverage limit for preventive dental benefits every year

Hearing Services	Authorization rules may apply.
	In general supplemental routine hearing exams and hearing aids not covered.
	$0 copay for Medicare-covered diagnostic hearing exams

Vision Services	Authorization rules may apply.
	$0 copay for diagnosis and treatment for diseases and conditions of the eye
	and up to 1 supplemental routine eye exam(s) every year
	$0 copay for one pair of eyeglasses or contact lenses after cataract surgery
	up to 1 pair(s) of glasses every year
	up to 1 pair(s) of contacts every year
	up to 1 pair(s) of lenses every year
	up to 1 frame(s) every year
	$100 plan coverage limit for eye wear every year.
	Plan offers additional vision benefits. Contact plan for details.

Over-the-Counter Items	The plan does not cover Over-the-Counter items.

Transportation	Authorization rules may apply.
	$0 copay for up to 20 one-way trip(s) to plan-approved location every year

Acupuncture	This plan does not cover Acupuncture.

Premium and Other Important Information	In 2012 the monthly Part B Standard Premium is $99.90 and the annual Part B deductible amount is $140.
	If a doctor or supplier does not accept assignment their costs are often higher which means you pay more.
	Most people will pay the standard monthly Part B premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

Doctor and Hospital Choice	You may go to any doctor specialist or hospital that accepts Medicare.

Inpatient Hospital Care	In 2012 the amounts for each benefit period are: Days 1 - 60: $1 156 deductible Days 61 - 90: $289 per day Days 91 - 150: $578 per lifetime reserve day
	Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days.
	Lifetime reserve days can only be used once.
	"A ""benefit period"" starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have."

Inpatient Mental Health Care	In 2012 the amounts for each benefit period are: Days 1 - 60: $1 156 deductible Days 61 - 90: $289 per day Days 91 - 150: $578 per lifetime reserve day
	You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

Skilled Nursing Facility (SNF)	In 2012 the amounts for each benefit period after at least a 3-day covered hospital stay are: Days 1 - 20: $0 per day Days 21 - 100: $144.50 per day
	100 days for each benefit period.
	"A ""benefit period"" starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have."

Home Health Care	$0 copay.

Hospice	You pay part of the cost for outpatient drugs and inpatient respite care.
	You must get care from a Medicare-certified hospice.

Doctor Office Visits	20% coinsurance

Chiropractic Services	Supplemental routine care not covered
	20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

Podiatry Services	Supplemental routine care not covered.
	20% coinsurance for medically necessary foot care including care for medical conditions affecting the lower limbs.

Outpatient Mental Health Care	40% coinsurance for most outpatient mental health services
	Specified copayment for outpatient partial hospitalization program services furnished by a hospital or community mental health center (CMHC). Copay cannot exceed the Part A inpatient hospital deductible.
	"""Partial hospitalization program"" is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor's or therapist's office and is an alternative to inpatient hospitalization."

Outpatient Substance Abuse Care	20% coinsurance

Outpatient Services/Surgery	20% coinsurance for the doctor's services
	Specified copayment for outpatient hospital facility services Copay cannot exceed the Part A inpatient hospital deductible.
	20% coinsurance for ambulatory surgical center facility services

Ambulance Services	20% coinsurance

Emergency Care	20% coinsurance for the doctor's services
	Specified copayment for outpatient hospital facility emergency services.
	Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital.
	You don't have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit.
	Not covered outside the U.S. except under limited circumstances.

Urgently Needed Care	20% coinsurance or a set copay
	NOT covered outside the U.S. except under limited circumstances.

Outpatient Rehabilitation Services	20% coinsurance

Durable Medical Equipment	20% coinsurance

Prosthetic Devices	20% coinsurance

Diabetes Programs and Supplies	20% coinsurance for diabetes self-management training
	20% coinsurance for diabetes supplies
	20% coinsurance for diabetic therapeutic shoes or inserts

Diagnostic Tests X-Rays Lab Services and Radiology Services	20% coinsurance for diagnostic tests and x-rays
	$0 copay for Medicare-covered lab services
	Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests like checking your cholesterol.

Cardiac and Pulmonary Rehabilitation Services	20% coinsurance Cardiac Rehabilitation services 20% coinsurance for Pulmonary Rehabilitation services 20% coinsurance for Intensive Cardiac Rehabilitation services
	This applies to program services provided in a doctor+s office. Specified cost sharing for program services provided by hospital outpatient departments.

Preventive Services and Wellness/Education Programs	No coinsurance copayment or deductible for the following:
	Abdominal Aortic Aneurysm Screening Bone Mass Measurement. Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions. Cardiovascular Screening Cervical and Vaginal Cancer Screening. Covered once every 2 years. Covered once a year for women with Medicare at high risk. Colorectal Cancer Screening Diabetes Screening Influenza Vaccine Hepatitis B Vaccine for people with Medicare who are at risk HIV Screening. $0 copay for the HIV screening but you generally pay 20% of the Medicare-approved amount for the doctor+s visit. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Breast Cancer Screening (Mammogram). Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35-39. Medical Nutrition Therapy Services Nutrition therapy is for people who have diabetes or kidney disease (but aren+t on dialysis or haven+t had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian and may include a nutritional assessment and counseling to help you manage your diabetes or kidney disease Personalized Prevention Plan Services (Annual Wellness Visits) Pneumococcal Vaccine. You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information. Prostate Cancer Screening + Prostate Specific Antigen (PSA) test only. Covered once a year for all men with Medicare over age 50. Smoking Cessation (counseling to stop smoking). Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period. Each counseling attempt includes up to four face-to-face visits. Welcome to Medicare Physical Exam (initial preventive physical exam) When you join Medicare Part B then you are eligible as follows. During the first 12 months of your new Part B coverage you can get either a Welcome to Medicare Physical Exam or an Annual Wellness Visit. After your first 12 months you can get one Annual Wellness Visit every 12 months.

Kidney Disease and Conditions	20% coinsurance for renal dialysis
	20% coinsurance for kidney disease education services

Outpatient Prescription Drugs	Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan or you can get all your Medicare coverage including prescription drug coverage by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage.

Dental Services	Preventive dental services (such as cleaning) not covered.

Hearing Services	Supplemental routine hearing exams and hearing aids not covered.
	20% coinsurance for diagnostic hearing exams.

Vision Services	20% coinsurance for diagnosis and treatment of diseases and conditions of the eye.
	Supplemental routine eye exams and glasses not covered.
	Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery.
	Annual glaucoma screenings covered for people at risk.

Over-the-Counter Items	Not covered.

Transportation	Not covered.

Acupuncture	Not covered.

Point of Service	You may go to any doctor specialist or hospital that accepts Medicare.

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Medicare Terms

• Co-payment: An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor's visit, hospital outpatient visit, or a prescription. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor's visit or prescription.
• Cost Plans: A type of Medicare health plan available in some areas. In a Medicare Cost Plan, if you get services outside of the plan's network without a referral, your Medicare-covered services will be paid for under Original Medicare (your Cost Plan pays for emergency services, or urgently needed services).
• Deductible: The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay.
• HMO - Health Maintenance Organization: Local HMOs are plans with defined networks of providers, which beneficiaries must use in order to receive coverage, serving specific geographic areas consisting of aggregations of counties.
• HMO SNP - Special Needs Plan: Medicare Special Needs Plans are a type of Medicare Advantage Plan (Part C) for people with certain chronic diseases and conditions or who have specialized needs (such as people who have both Medicare and Medicaid or people who live in certain institutions). Medicare SNPs provide their members with all Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance) services, and Medicare prescription drug coverage (Part D). Medicare SNPs were created to give certain groups of people better access to Medicare with plans designed to meet their unique needs.
• HMO with POS Option: An HMO POS is a Medicare Advantage Plan that is a Health Maintenance Organization with a more flexible network allowing Plan Members to seek care outside of the traditional HMO network under certain situations or for certain treatment.
• LPPO - Local Preferred Provider Organization: Local PPOs are network based plans that serve specific geographic areas consisting of aggregations of counties, like HMOs, but with more flexibility in provider choice within the network. Beneficiaries may use providers outside the network but will pay more out of pocket cost.

See All Terms

Related Links

Medicare.gov The official U.S. Government site for Medicare
AARP American Association of Retired Persons
HHS.gov United States Department of Health & Human Services
CMS.gov Centers for Medicare & Medicaid Services
Social Security Administration The official website of the U.S. Social Security Administration

HealthyAdvantage Primary Plan (HMO)(H4454-028)

HealthyAdvantage Primary Plan (HMO)
(H4454-028)